Download The HIV Epidemic in Oakland, 2012-2014

The HIV Epidemic in Oakland, 2012-2014
Oakland is Alameda County’s largest city and has a diverse population. East and West Oakland communities
experience among the highest rates of poverty, unemployment, housing cost burden, and lack of health insurance
coverage, and among the lowest high school graduation rates in the county. Oakland residents have a lower life
expectancy and a higher burden of mortality and morbidity from chronic disease, injuries, substance use, and severe
mental illness than the county.1
Oakland also experiences a disproportionate burden of HIV and AIDS in the county. In 2010, one in four of Alameda
County residents lived in Oakland, yet one in two new diagnoses of HIV in Alameda County during 2012 to 2014
occurred among Oakland residents. The overall rate of new HIV diagnoses in Oakland was twice the rate in the county
as a whole.2 Unfavorable social and economic conditions in several West and East Oakland neighborhoods likely
contribute to the profound racial/ethnic inequities in HIV burden in Oakland.
To address the high burden of HIV, in October 2015 the City of Oakland signed on to the Fast-Track Cities
Initiative3—an initiative to reduce global HIV rates by focusing on high HIV burden cities around the world. This
report highlights key features of the Oakland HIV epidemic and its progress towards the targets set by the Fast-Track
Cities Initiative.
New Diagnoses of HIV
Counts and rates of new HIV diagnoses in Oakland during 2012 to 2014 by sex, race/ethnicity, and age group are
presented in Table 1 (Appendix).4 Between 2012 and 2014, 113.3 people on average per year were diagnosed with HIV in
Oakland. The vast majority of these diagnoses were among men. African Americans accounted for over half of all new
diagnoses, followed by Latinos who comprised about 20%. African Americans had an over five times higher HIV
diagnosis rate during 2012 to 2014 compared to Asians and Pacific Islanders (API), and a three times higher rate than
whites (Figure 1). Persons aged 20 to 49 accounted for the majority of diagnoses; those aged 20 to 29 accounted for about
30% of all new diagnoses. The lowest diagnosis rates among all age groups occurred among those aged 19 or younger and
60 years or older.
Figure 1: HIV Diagnosis Rates by Race/Ethnicity, Oakland, 2012‐2014 African Americans have the highest
diagnosis rate of all racial/ethnic groups in
Oakland by far— nearly 60 new cases per
100,000 persons. Asians and Pacific
Islanders (API) have the lowest rates.5
Note: “AfrAmer”=African American, “API”= Asian and Pacific Islander
1
Figure 2: Trends in HIV Diagnosis Rates by Race/Ethnicity in Men, Oakland, 2006‐2014 Figure 3: Trends in HIV Diagnosis Rates by Race/Ethnicity in Women, Oakland, 2006‐2014 Note: “AfrAmer”=African American, “API”= Asian and Pacific Islander
Between 2006 and 2014 rates of new HIV diagnoses remained relatively stable among Latino and API men, and
decreased among white men (Figure 2). Rates among African American men also decreased during this time period, but
continued to be the highest of all racial/ethnic groups. During 2012 to 2014, African American men were three times more
likely to be diagnosed with HIV than white men, and a four times more likely to be diagnosed with HIV than API men.
A large drop in HIV cases among women occurred between 2006 and 2014, particularly among African American women
(Figure 3). However, African American women continue to experience the highest rates of HIV among women. Rates
among white, Latino, and API women have remained low during this time period, with less than 10 new diagnoses on
average annually in each group. During 2012 to 2014, African American women in Oakland were eight times more likely
to be diagnosed with HIV compared to white women.
Figure 4: Mode of Transmission by Sex,
Oakland, 2012‐2014 Men having sex with men (MSM) was
the most common mode of transmission
for new HIV diagnoses among men in
Oakland from 2012 to 2014 (Figure 4).
MSM made up about 80% of diagnoses
among men and 67% of diagnoses
overall. Among women with a
documented risk factor, heterosexual
contact was the most common mode of
transmission, followed by intravenous
drug use (IDU).6
2
People Living with HIV
Table 2 (Appendix) presents data for people living with HIV (PLHIV) residing in Oakland at the end of 2014. There were
3,275 PLHIV living in Oakland, including people with stage 3 HIV infection (AIDS)—this represented nearly 60% of all
PLHIV residing in Alameda County. The large majority of PLHIV in Oakland were men (over 80%). Over half of PLHIV
in Oakland were African American and one-fourth was white. Among male PLHIV 40% were African American; API
made up the smallest proportion of PLHIV. Though the highest rates of new diagnosis during 2012 to 2014 occurred
among people aged 20 to 49, over half of PLHIV in Oakland were aged 50 or over. The growing number of older PLHIV
in Oakland is consistent with the epidemics in Alameda County and the United States—a consequence of longer survival
with improved HIV treatment in recent years.
Figures 5 and 6 illustrate the geographic distribution of residents living in poverty in Oakland7 and rate of PLHIV in
Oakland (prevalence) at the end of 2014, respectively. HIV prevalence in Oakland is substantially higher in the
Downtown, West Oakland, San Antonio, and East Oakland (Oakland Flats) neighborhoods compared to the North- and
Southwest Hills and Lower Hills (Oakland Hills) neighborhoods.8 This distribution closely mirrors the distribution of
poverty in Oakland neighborhoods.
Figure 5: Percent Residents Living in Poverty by Census Tract, Oakland 2014 3
Figure 6: Prevalence of HIV by Census Tract, Oakland, Year‐End 2014 Source: HIV Epidemiology and Surveillance Unit, with data from eHARS 2015 Q2 files.
Fast-Track Cities Indicators
The Fast-Track Cities Initiative is an initiative led by international HIV/AIDS relief organizations and local governments
to improve and accelerate HIV/AIDS response in urban environments where much of the global HIV burden lies. It uses
the "90-90-90 targets": that 90% of PLHIV will know their HIV status; 90% of those who are HIV positive and know
their status will be on HIV treatment (antiretroviral therapy, or ART); and 90% of those on HIV treatment will be virally
suppressed (have a low level of the HIV virus in their blood).3 While Oakland data are not available for all of these
measures, data on selected indicators provide useful insights into the state of the HIV epidemic in Oakland. These
measures include: late diagnosis; linkage to care; retention in care; and viral suppression.
4
Late Diagnosis
Figure 7: Late Diagnosis by Race/Ethnicity,
Oakland, 2011‐2013 Figure 8: Late Diagnosis by Age,
Oakland, 2011‐2013 Note: “AfrAmer”=African American, “API”= Asian and Pacific Islander
Late diagnosis—or diagnosis of HIV late in the course of infection—is an important measure of the current epidemic, as
those who do not know their HIV status and are not virally suppressed contribute considerably to the spread of HIV. A
notable difference in the pattern of late diagnoses in Oakland compared to that in Alameda County as a whole was by
race/ethnicity (Figure 7). While there were only minor differences in timely HIV diagnosis across racial/ethnic groups in
the county, people of color in Oakland had substantially higher proportions of late diagnosis than whites.2 While API
appear to have a high proportion of late HIV diagnoses, this finding should be considered with caution as it is based on a
small number of cases among API and may represent a variable or unstable estimate. Differences in late diagnosis were
also seen by age group (Figure 8). Among newly diagnosed persons aged 50 to 59, over 60% were late; this may represent
a gap in testing of older populations at risk for HIV. Among people aged 20 to 29, a third of new diagnoses were late.
Among newly diagnosed MSM, about 43% were diagnosed late. Men were more likely to be diagnosed late (44%) than
women (28%).
Linkage to Care
Linkage to HIV care is defined as the proportion of those newly diagnosed with HIV who had a HIV care visit within 90
days of diagnosis. The proportion linked was calculated both including as well as excluding lab tests done on the date of
diagnosis. When examined including labs done on the date of diagnosis, 84% of all those diagnosed between 2011 and
2013 were linked to care within 90 days or less; when excluding the date of diagnosis, the proportion linked was 73%
(data not shown). Men and women had similar proportions linked to care including the date of diagnosis (around 84%)
and excluding the date of diagnosis (around 73%). APIs had a much higher proportion of linkage to care within 90 days or
less by both definitions (100% including, and 88% excluding diagnosis date) compared to other racial/ethnic groups with
proportion linked 83-85% including and 72-73% excluding diagnosis date.
Retention in Care
One measure of retention in care among PLHIV is measured by the proportion that had at least one visit in 2013. Of all
PLHIV residing in Oakland throughout 2013, 75% had at least one visit in 2013. The proportion of PLHIV with a single
visit varied by age and race/ethnicity. Latinos had the lowest proportion of all racial/ethnic groups (Figure 9) and those 30
to 39 years old had the lowest proportion with a single visit among all age groups (Figure 10).
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Another measure of retention in care is the proportion of PLHIV who had two or more visits that were 90 or more days
apart. In 2013, 58% of all PLHIV in Oakland were retained in care. White and API PLHIV had the highest and African
Americans and Latinos had the lowest retention in care among all racial/ethnic groups. Those aged 30 to 39 had the lowest
retention in care among all age groups.
Figure 9: Retention in Care by Race/Ethnicity,
Oakland, 2013 Figure 10: Retention in Care by Age,
Oakland, 2013 Note: “AfrAmer”=African American, “API”= Asian and Pacific Islander
Viral Load
Viral load tests are used to determine the amount of the HIV virus in the blood at a given time. Viral load is an important
measure because people with high amounts of virus in the blood are the most infectious to others, making them major
drivers of the HIV epidemic. People living with HIV can take antiretroviral therapy—medication that reduces their viral
load and strengthens their immune system—which minimizes the risk of ongoing transmission. Attainment of viral
suppression among 90% of individuals on antiretroviral therapy is a key target in the Fast-Track Cities Initiative.8-9
Among all people living with HIV or AIDS at year end 2014 in Oakland, 60% had a suppressed or undetectable viral load
and 12% were unsuppressed.10, 11 African Americans and Latinos had the lowest proportions of virally suppressed or
undetectable individuals (58% for both) of all racial/ethnic groups and whites and API the highest proportions (67% and
69% respectively). Viral suppression generally increased with age, with PLHIV aged 20-29 having the lowest proportions
(48% suppressed) and those aged 60 and over the highest (69%).
The profile of the Oakland HIV epidemic presented in this brief highlights the substantially higher burden of HIV among
people of color, in particular African Americans and Latinos, as well as those in low-income neighborhoods in Oakland.
The data also highlight the profound racial/ethnic inequities in timely HIV diagnosis, engagement in care, and virologic
suppression.
These findings highlight the need to strengthen policies and programs tailored to the communities most impacted by the
HIV epidemic in Oakland, specifically those that reduce social and economic barriers to HIV prevention and care.
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Appendix: Data Tables
Table 1. New HIV Diagnoses by Selected Characteristics, Oakland, 2012-2014
Average
Annual
total
Percent of
Oakland
diagnoses
Diagnosis Rate per
100,000 (three-year
average)
95%
Confidence
Interval
Male
113.3
95.3
100.0%
84.1%
28.5
49.3
(23.2 - 33.7)
(39.4 - 59.2)
Female
18.0
15.9%
8.8
(6.6 - 11.5)
a
All diagnoses in
Oakland
Sex
African
American
63.3
55.9%
59.8
White
18.0
15.9%
17.5
Latino
22.7
20.0%
21.6
API
7.7
6.8%
11.1
Other/
Unknown
*
*
**
Age Group
0 - 12
*
*
**
13 - 19
5.0
4.4%
16.3
20 - 29
34.3
30.3%
56.9
30 - 39
26.7
23.5%
41.1
40 - 49
29.7
26.2%
52.1
50 - 59
12.7
11.2%
24.6
60 & over
4.7
4.1%
6.6
Notes: 1) “*” = count not displayed due to small numbers; 2) “**” = rates unstable or not calculable
Race/Ethnicity
(45.1 - 74.5)
(13.2 -22.9)
(16.7 - 27.3)
(7.0 - 16.6)
**
**
(9.1 - 26.8)
(37.9 - 75.9)
(32.6 - 51.2)
(41.9 - 64.1)
(17.4 - 33.8)
(3.6 - 11.1)
Table 2. People Living with HIV by Selected Characteristics, Oakland, Year End 2014
a
All PLHIV in
Oakland
Sex
Male
Female
Race/Ethnicity
Age Group
African
American
Count
Percent of
PLHIV
Prevalence per
100,000
95% Confidence
Interval
3,275
100.0%
814.8
(786.9 - 842.7)
2,672
81.6%
1,367.4
(1,315.5 - 1,419.2)
603
18.4%
292.0
(268.7 - 315.3)
1,753
53.5%
1,753.4
(1,654.2 - 1,816.6)
White
855
26.1%
819.2
(764.3 - 874.1)
Latino
479
14.6%
445.6
(405.7 - 485.5)
API
Other/
Unknown
139
4.2%
192.8
(160.8 - 224.9)
49
1.5%
*
**
**
**
**
0 - 12
*
13 - 19
10
0.3%
33.0
(15.8 - 60.7)
20 - 29
234
7.2%
385.7
(336.3 - 435.1)
30 - 39
40 - 49
50 - 59
495
844
1,024
15.1%
25.8%
31.3%
753.5
1,480.4
1,926.6
(687.1 - 819.8)
(1,380.6 - 1,580.3)
(1,808.6 - 2,044.6)
60 & over
663
20.2%
909.7
(840.5 - 979.0)
Notes: 1) “*” = count not displayed due to small numbers; 2) “**” = rates unstable or not calculable
7
Sources and Technical Notes
1.
Source: Map Set. Alameda County Public Health Department, Community, Assessment, Planning, Education and
Evaluation (CAPE) Unit. 2015. http://www.acphd.org/media/408752/ac_maps.pdf
2. Source: Alameda County Public Health Department. HIV in Alameda County, 2012-2014. http://www.acphd.org/datareports/reports-by-topic/hivaids.aspx. Published July 2016.
3. Fast-Track Cities. http://iapac.org/cities/
4. Rates are averaged across the three year period from 2012 to 2014. “Sex” here refers to the sex assigned at birth.
5. The bars in black represent the 95% confidence intervals of the rates.
6. Over half of newly reported diagnoses among women did not include information on mode of transmission. These cases
likely acquired HIV through heterosexual contact, but are not documented as such because the CDC’s criteria for a
person’s mode of transmission to be classified as “heterosexual contact” requires that one or more risk factors are
documented for that person’s partner(s). This information is often not known to providers or documented in medical
records.
7. Map provided by Alameda County Health Department, CAPE Unit.
8. In Oakland, areas with high poverty rates are found in North Oakland, West Oakland, Downtown and Chinatown, San
Antonio, Fruitvale, Central East Oakland, and Elmhurst neighborhoods and are referred to as the Flats. The Lower Hills,
Northwest Hills, and Southwest Hills neighborhoods are high-income (i.e., have low poverty rates) and are known as the
Oakland Hills.
9. It is important to note that while the Fast-Track Cities goal for 90% viral suppression is out of the total number of people
on antiretroviral medication, HIV surveillance data does not capture information on medication use. The measure of viral
suppression used here is a proportion of the total number of people living with HIV and not the total number of people on
antiretroviral medication.
10. Viral load suppression is defined here as follows: an undetectable viral load is a viral load of ≤75 copies of the HIV virus
per milliliter of blood; a “suppressed” viral load is between 76-199 copies per milliliter; and an “unsuppressed” viral load
is 200 or more copies per milliliter.
11. Of all PLHIV in Oakland only 16.7% had a CD4 count reported for 2014 (no viral load test) and 24.5% did not have a CD4
or viral load test reported for 2014.These individuals were not included in these estimates of viral suppression.
Acknowledgements
This report was produced by Juliet Nussbaum. Project guidance and direction as well as editorial review were provided by
Neena Murgai. Review, comments, and data analysis support were provided by Richard Lechtenberg.
Available online at: http://www.acphd.org/data-reports/reports-by-topic/hivaids.aspx.
Suggested citation: Alameda County Public Health Department. The HIV Epidemic in Oakland, 2012-2014.
http://www.acphd.org/data-reports/reports-by-topic/hivaids.aspx. Published August 2016. Accessed [date].
Alameda County Public Health Department
HIV Epidemiology and Surveillance Unit
1000 Broadway, Suite 310 Oakland, CA 94607
Phone: (510) 268-2372
8